N94.19 — Other specified dyspareunia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Chronic sialorrhea — documentation member is refractory to pharmacotherapy (e.g., anticholinergics).
- Anal fissures — documentation of failure to first-line therapy such as topical calcium channel blockers or topical nitrates.
- Hirschsprung disease with internal sphincter achalasia — documentation that treatment is after endorectal pull-through and refractory to laxative therapy.
- Services are covered 'if selection criteria are met' — documentation should demonstrate that the applicable selection criteria (as referenced in the policy) are met for the specific product and indication.
Key Coverage Criteria
- OnabotulinumtoxinA (Botox) medically necessary indications (initial approval): Achalasia — Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.
- Botulinum toxin type A has become 1st-line therapy for Frey's syndrome.
- Botulinum toxin type A therapy for blepharospasm
- Botulinum toxin for chronic low back pain
- Botulinum toxin for Raynaud's phenomenon / ischemic digits
- Botulinum toxin for temporomandibular disorders
3 Active Policies
AETNA-CPB-0113 — Botulinum Toxin
AETNA-CPB-0427 — Carbon Dioxide Laser
AETNA-CPB-0574 — Female Sexual Dysfunction (FSD)
Related Codes
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